Principles of Patients’ Management with Abdominal Hernia in Family Doctor’s Practice. Surgical Pathology of the Rectum in the Outpatient Department of Family Doctor. Diagnosis, patient’s referral, rehabilitation, prophylactic medical examination. Medical and Labour Expert Examination.
Hernia
A hernia is an outpouching of the parietal peritoneum through a preformed or secondarily established hiatus. If the hernia extends beyond the abdominal cavity and is thus visible on the surface of the body, it is defined as an external hernia. If the outpouching is limited to peritoneal pockets, it is known as an internal hernia. An intermediate position is taken by the interparietal hernias of the abdominal wall. Hernias may include intra- and retroperitoneal organs, either permanently or intermittently. Depending on the size of the outpouching, we speak of complete (total) or incomplete (partial) hernias. Based on their formation, we distinguish between congenital (e.g., umbilical hernias and indirect inguinal hernias, if the processus vaginalis is open) and acquired hernias (e.g., direct, femoral, and incisional hernias).
History.
The first description of an inguinal hernia appears in the Ebers papyrus (1555 B.C.). Hippocrates (460–375 B.C.) mentions hernias of the pubic and umbilical regions. The first anatomical studies of the inguinal region date back to Galen (131–210 A.D.).
Disregarding the historical precursors of inguinal hernia management by barbers, rupture cutters, and bathing masters, the real history of inguinal hernia surgery begins at the end of the nineteenth century. The first attempts to reduce the hernial orifice were made by Marcy (1871), Steele (1874), and Czerny (1887). It was Bassini in 1890 who introduced and established tactical surgical principles with excellent results by repairing the posterior wall of the inguinal canal and reducing of the internal inguinal ring. It was only in the middle of the twentieth century that Bassini’s concept was improved by Shouldice (1945) and McVay and Anson (1942), showing the importance of the fascia transversalis.
The use of fascia grafts to close large hernial orifices and recurrent hernias dates back to Halsted (1903), Kirschner (1908), Rehn (1914), and Koontz (1926). The use of alloplastic material was introduced by Stock (1954) and Usher (1962). Preperitoneal mesh-implantation was first described by Rives (1965) for unilateral hernias and by Stoppa (1968) for bilateral inguinal hernias. In 1970, it was Lichtenstein who advocated and used mesh to bolster the repair of both direct and recurrent hernias.
The first laparoscopic hernia repair was performed by Ger (1982), by simply closing the peritoneal opening with staples without dissection, ligation, or reduction of the sac. In 1989, it was Bogojavalensky to revived this procedure by introducing the mesh-plug technique. The first series of laparoscopic herniorrhaphies were published by Schultz in 1990. Since that time, three laparoscopic procedures have been established: intra-abdominal onlay mesh- (IPOM, Fitzgibbons and Toy 1990), the transabdominal preperitoneal mesh- (TAPP, Arregui 1991), and total extraperitoneal mesh- (TEP, Dulucq 1991) implants (2).
Pathogenesis
The pathogenesis of hernias is multifactorial. Congenital hernias are preformed hernial openings caused by incomplete closure of the abdominal wall (e.g., persistent processus vaginalis), while, in acquired hernias, the cause is increasing dehiscence of fascial structure with accompanying loss of abdominal wall strength. The develop typically in locations where larger blood vessels or the spermatic cord lie, or where previous incisions were made.
Different etiological factors, such as increased intra-abdominal pressure (in pregnancy, intra-abdominal tumors, chronic obstructive lung disease, ascites, chronic intestinal obstruction, and adiposity), or pathological changes in connective tissue of the abdominal wall, are blamed, without conclusive significance. New material for understanding the pathogenetics has been provided by recent studies on collagen metabolism disorder, in which an increase of collagen III war proven in patients with hernia.
Epidemiology
The incidence of inguinal hernia in the population varies between 2% and 4%, increasing with age up to 20%. In 95% of cases, hernias are external, and in 5% they are internal. Of all hernias, 75% are inguinal (two thirds indirect and one third direct); 10% are incisional, and 5–7% are umbilical, femoral, or in other, rare locations. Whereas about 80–90% of inguinal hernias occur in males, 75% of all femoral hernias are found in females. With over 750,000 inguinal hernia operations per year in the
A hernia is protrusion of an organ or the muscular wall of an organ through the cavity that normally contains it. A hiatal hernia occurs when the stomach protrudes upwards into the mediastinum through the esophageal opening in the diaphragm.
By far the most common herniae develop in the abdomen, when a weakness in the abdominal wall evolves into a localized hole, or “defect”, through which adipose tissue, or abdominal organs covered with peritoneum, may protrude. Another common hernia involves the spinal discs and causes sciatica.
Herniae may or may not present either with pain at the site, a visible or palpable lump, or in some cases by more vague symptoms resulting from pressure on an organ which has become “stuck” in the hernia, sometimes leading to organ dysfunction. Fatty tissue usually enters a hernia first, but it may be followed by or accompanied by an organ.
Most of the time, herniae develop when pressure in the compartment of the residing organ is increased, and the boundary is weak or weakened.
•Weakening of containing membranes or muscles is usually congenital (which explains part of the tendency of herniae to run in families), and increases with age (for example, degeneration of the annulus fibrosus of the intervertebral disc), but it may be on the basis of other illnesses, such as Ehlers-Danlos syndrome or Marfan syndrome, stretching of muscles during pregnancy, losing weight in obese people, etc., or because of scars from previous surgery.
•Many conditions chronically increase intra-abdominal pressure, (pregnancy, ascites, COPD, dyschezia, benign prostatic hypertrophy) and hence abdominal hernias are very frequent. Increased intracranial pressure can cause parts of the brain to herniate through narrowed portions of the cranial cavity or through the foramen magnum. Increased pressure on the intervertebral discs, as produced by heavy lifting or lifting with improper technique, increases the risk of herniation.
Examples include:
•abdominal hernias
•diaphragmatic hernias and hiatal hernias (for example, paraesophageal hernia of the stomach)
•pelvic hernias, for example, obturator hernia
•anal hernias
•hernias of the nucleus pulposus of the intervertebral discs
•intracranial hernias
•Spigelian hernias
Each of the above hernias may be characterized by several aspects:
•congenital or acquired: congenital hernias occur prenatally or in the first year(s) of life, and are caused by a congenital defect, whereas acquired hernias develop later on in life. However, this may be on the basis of a locus minoris resistentiae (Lat. place of least resistance) that is congenital, but only becomes symptomatic later in life, when degeneration and increased stress (for example, increased abdominal pressure from coughing in COPD) provoke the hernia.
•complete or incomplete: for example, the stomach may partially or completely herniate into the chest.
•internal or external: external ones herniate to the outside world, whereas internal hernias protrude from their normal compartment to another (for example, mesenteric hernias).
•intraparietal hernia: hernia that does not reach all the way to the subcutis, but only to the musculoaponeurotic layer. An example is a Spigelian hernia. Intraparietal hernias may produce less obvious bulging, and may be less easily detected on clinical examination.
•bilateral: in this case, simultaneous repair may be considered, sometimes even with a giant prosthetic reinforcement.
•irreducible (also known as incarcerated): the hernial contents cannot be returned to their normal site with simple manipulation.
If irreducible, hernias can develop several complications (hence, they can be complicated or uncomplicated):
•strangulation: pressure on the hernial contents may compromise blood supply (especially veins, with their low pressure, are sensitive, and venous congestion often results) and cause ischemia, and later necrosis and gangrene, which may become fatal.
•obstruction: for example, when a part of the bowel herniates, bowel contents cao longer pass the obstruction. This results in cramps, and later on vomiting, ileus, absence of flatus and absence of defecation.
•dysfunction: another complication arises when the herniated organ itself, or surrounding organs, start to malfunction(for example, sliding hernia of the stomach causing heartburn, lumbar disc hernia causing sciatic nerve pain, etc.).
European Hernia Society classification for primary abdominal wall hernias
Classification of incisional abdominal wall hernias
Definition of incisional hernia
It was decided to use the definition proposed by Korenkov et al: “Any abdominal wall gap with or without a bulge in the area of a postoperative scar perceptible or palpable by clinical examination or imaging”.
An incisional hernia occurs when the defect is the result of an incompletely healed surgical wound. When these occur in median laparotomy incisions in the linea alba, they are termed ventral hernias. These can be the most frustrating and difficult to treat, as the repair utilizes already attenuated tissue.
Choice of variables used to classify
The task of developing a good classification for incisional hernias is much more difficult than for groin hernias or for primary abdominal wall hernias because of their great diversity. On the other hand, because of this diversity a classification is highly desirable in this group of hernias. The question remains as to whether a simple classification can cover the complexities of the great diversity of incisional hernias and their different variables.
There was a consensus that the localisation of the hernia on the abdominal wall and the size of the hernia defect are essential for classifying. There was less agreement on the inclusion of the number of previous hernia repairs as a variable for classifying. Including more variables in the classification will make it more complex and less practical. Other variables and risk factors will be part of the above-mentioned registry, but for the present, will not be part of a simple classification.
Localisation of the hernia
The abdomen was divided into a medial or midline zone and a lateral zone.
Medial or midline hernias
The borders of the midline area are defined as:
1. cranial: the xyphoid
2. caudal: the pubic bone
3. lateral: the lateral margin of the rectal sheath
Thus, all incisional hernias between the lateral margins of both rectus muscle sheaths are classified as midline hernias.
The Chevrel classification uses three midline zones. Our group agreed that hernias close to bony structures have separate subgroups. They pose specific therapeutic approaches and have an increased recurrence risk. An easily memorable classification from M1 to M5 going from the xiphoid to pubic bone was proposed. Therefore, we define
1. M1: subxiphoidal (from the xiphoid till
2. M2: epigastric (from
3. M3: umbilical (from
4. M4: infraumbilical (from
5. M5: suprapubic (from pubic bone till
To classify midline incisional hernias between the two lateral margins of the rectus muscle sheaths, five zones were defined
Lateral hernias
The borders of the lateral area are defined as
1. cranial: the costal margin
2. caudal: the inguinal region
3. medially: the lateral margin of the rectal sheath
4. laterally: the lumbar region.
To classify lateral incisional hernias, four zones lateral of the rectus muscle sheaths were defined
Thus, four L zones on each side are defined as:
1. L1: subcostal (between the costal margin and a horizontal line
2. L2: flank (lateral to the rectal sheath in the area
3. L3: iliac (between a horizontal line
4. L4: lumbar (latero-dorsal of the anterior axillary line)
Size of the hernia
In contrast to primary abdominal wall hernias, incisional hernias come in many different sizes and shapes. So the size of an incisional hernia is not easily captured in only one variable or measurement. For classification in the two-dimensional grid format, it is essential to bring the variable “size of the hernia defect” in one quantitative or semi-quantitative measure. Chevrel solved this problem by choosing the width of the hernia defect as the one parameter to classify, stating that the width is the most important measurement of size to determine the difficulty of succesfully repairing the hernia.
There was a consensus that the width of the hernia defect alone was insufficient to describe the hernia defect size adequately. We agreed that width and length should be used. This means that for a “grid format” both width and length have to be combined in one measurement.
The width of the hernia defect was defined as the greatest horizontal distance in cm between the lateral margins of the hernia defect on both sides. In case of multiple hernia defects, the width is measured between the most laterally located margins of the most lateral defect on that side
Definition of the width and the length of incisional hernias for single hernia defects and multiple hernia defects
The length of the hernia defect was defined as the greatest vertical distance in cm between the most cranial and the most caudal margin of the hernia defect. In case of multiple hernia defects from one incision, the length is between the cranial margin of the most cranial defect and the caudal margin of the most caudal defect.
Hernia defect surface can be measured by combining width and length in a formula for an oval, thus trying to make an estimation of the real surface in cm2. This option was not withheld, because many incisional hernias are not oval shaped, and many hernias have multiple defects, making the correct estimation of hernia defect size difficult.
Because no consensus was reached on the variable “size of the hernia defect”, it was not possible to make a “grid format” for an EHS classification for incisional abdominal wall hernias. Instead, the grid could be made for the localisation variable with space to note width and length correctly in cm. A semi-quantitative division, taking only the width as measurement for the size, was accepted to be included in the classification table. To avoid confusion with primary abdominal wall hernias (small, medium and large), a coded taxonomy was chosen (W1 < 4 cm; W2 ≥ 4–10 cm; W3 ≥ 10 cm) instead of a nominative one.
Previous hernia repairs
Several participants in the meeting considered that if an incisional hernia is a recurrence after previous repair of a hernia—either incisional or primary—then this variable should be included in the classification. The number of previous hernia repairs was not considered of enough importance to include in the table. A simple yes or no answer was chosen.
Several questions arose from this classification:
1. How should hernias extending over more than one M zone be classified? No consensus was reached on this. One proposal was to allocate hernias to the M zone that is generally considered as the more difficult or more representative for the hernia. They are, in order of importance: first subxyphoidal (M1) and suprapubic (M5), then umbilical (M3) and finally epigastric (M2) and infraumbilical (M4). This would avoid making further subgroups (e.g. M1-2/M1-2-3/M2-3-4). So a hernia extending from M1 over M2 to M3 (thus from subxyphoidal to the umbilicus) would be classified as M1 (thus as a subxiphoidal hernia). A hernia extending from M2 over M3 to M4 (thus from epigastric to infraumbilical) would be classified as M3 (thus as an umbilical hernia). No consensus was reached on this. It was decided to mark every zone in which the hernia was located when using the grid for incisional hernias.
2. How should incisional hernias with multiple defects be classified? Different hernia defects caused by one incision will be considered as one hernia. If the different defects were caused by two different incisions, they should be considered two different hernias.
Midline and lateral hernias abdominal wall
Treatment
There are many ways to surgically repair incisional hernias. Smaller incisional hernias (<
Risks
The risks of incisional hernia repair include: seroma, wound infection, injury to intra-abdominal structures, and recurrent hernia. Major complications such as a mesh infection or enterocutaneous fistula may result in prolonged morbidity and require reoperation.
Expected Outcomes
Successful repair can be expected in the majority of cases. Recurrence rates range from 25-50% following an initial primary repair. The risk of recurrence increases dramatically in patients who have had previous failed repairs, in patients with very large hernias, obese patients, and in cases where one or more margins of the hernia defect is bone or cartilage. The use of a mesh support during open surgical repair has been shown to decrease recurrence rates to 5-35%. The early experience with laparoscopic repairs employing mesh has been favorable with recurrence rates as low as 1-10%. However, it must be emphasized that these studies reflect very short term (less than 3 years) follow-up periods. Furthermore, there is not yet any strong evidence based literature that directly compares laparoscopic to open approaches for this problem.
After surgery, patients are instructed to limit activity for varying lengths of time, according to surgeon preference. Limitations on lifting and straining are generally recommended for several weeks after surgery. Limitations on activity after the laparoscopic approach are generally of shorter duration than following traditional open repairs.
Qualifications for performing incisional hernia repairs
Surgeons who are certified or eligible for certification by the American Board of Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent should perform both elective and emergent incisional hernia repair. These surgeons have completed at least five years of surgical training after medical school graduation and are qualified to perform open incisional hernia repair with and without tension-free techniques. The level of training in advanced laparoscopic techniques necessary to conduct minimally invasive incisional herniorrhaphy has not been formally determined but surgeons with advanced laparoscopic experience are qualified to perform this procedure.
Hernia umbilicalis
Umbilical hernia
Umbilical hernias are especially common in infants of African descent, and occur more in boys. They involve protrusion of intraabdominal contents through a weakness at the site of passage of the umbilical cord through the abdominal wall. These hernias often resolve spontaneously.
Umbilical hernias in adults are largely acquired, and are more frequent in obese or pregnant women. Abnormal decussation of fibers at the linea alba may contribute.
Inguinal hernia
By far the most common hernias (up to 75% of all abdominal hernias) are the so-called inguinal hernias. Much insight is needed in the anatomy of the inguinal canal. Inguinal hernias are further divided into the more common indirect inguinal hernia (2/3, depicted here), in which the inguinal canal is entered via a congenital weakness at its entrance (the internal inguinal ring), and the direct inguinal hernia type (1/3), where the hernia contents push through a weak spot in the back wall of the inguinal canal. Inguinal hernias are the most common type of hernia in both men and women. Femoral hernias occur more often in women than men, but women still get more inguinal hernias than femoral hernias.
I. Anatomy, Nomenclature and Classification of Inguinal Hernia
The Inguinal Canal
* The anatomic space beneath the external oblique aponeurosis, between the
internal and external inguinal rings.
* In men, it contains the cremaster muscle and cord structures
(vas deferens, testicular vessels, and associated connective tissues).
* In women, it contains the cremaster muscle, round ligament of the uterus,
and some connective tissues.
Indirect Hernia
* Consists of sac of peritoneum coming through internal ring, antero-medial
to the spermatic cord (or round ligament) which omentum or bowel can enter.
* Usually congenital, but may be acquired.
* Virtually all hernias in patients under age 25 are indirect.
* Male/female ratio is about 9:1.
* Internal ring may be normal or dilated.
* Higher risk of incarceration/strangulation if large and extends into scrotum.
* [Technically, indirect hernias emerge lateral to the epigastric vessels. In
practical terms, this is an accurate but pretty useless definition.]
Direct Hernia
* Bulging as a result of weakness or attenuation of the posterior floor of the
inguinal canal, anywhere from the internal ring to the pubic bone.
* [Technically, medial to the epigastric vessels.]
* The hernia consists primarily of retroperitoneal fat; a peritoneal sac
containing bowel is only infrequently present.
* Usually at low (but not zero) risk for incarceration or strangulation.
* Rarely occurs in women.
Recurrent Hernia
* Any inguinal canal hernia which occurs after prior inguinal hernia repair.
* Most often direct, but may also be indirect or sliding.
Gilbert designed a classification for primary and recurrent inguinal hernias done through an anterior approach (Figure). It is based on evaluating 3 factors:
1. presence or absence of a peritoneal sac
2. size of the internal ring
3. integrity of the posterior wall of the canal.
Nyhus Classification of Inguinal Hernias
I. Indirect sac, normal internal ring.
II. Indirect sac, dilated internal ring
IIIA. Direct hernia
IIIB. Indirect hernia with weak inguinal floor; sliding hernia.
IIIC. Femoral hernia.
IV. Recurrent hernia (A=direct; B=indirect; C=femoral; D=other)
Figure. Gilbert classification. Five types of primary and recurrent inguinal hernias.
Types 1, 2 and 3 are indirect hernias; types 4 and 5 are direct.
- Type 1 hernias have a peritoneal sac passing through an intact internal ring that will not admit 1 fingerbreadth (ie,<
1 cm .); the posterior wall is intact. - Type 2 hernias (the most common indirect hernia) have a peritoneal sac coming through a 1-fingerbreadth internal ring (ie, ≤2 cm.); the posterior wall is intact.
- Type 3 hernias have a peritoneal sac coming through a 2-fingerbreadth or wider internal ring (ie, >
2 cm .). - Type 3 hernias frequently are complete and often have a sliding component. They begin to break down a portion of the posterior wall just medial to the internal ring.
- Type 4 hernias have a full floor posterior wall breakdown or multiple defects in the posterior wall. The internal ring is intact, and there is no peritoneal sac.
- Type 5 hernias are pubic tubercle recurrence or primary diverticular hernias. There is no peritoneal sac and the internal ring remains intact. In cases where double hernias exist, both types are designated (eg, Types 2/4). Descriptors such as L, Sld., Inc., Strang. Fem. are used to designate lipoma, sliding component, incarceration, strangulation and femoral components.
Diagnosis of Inguinal Hernia
Pain is sometimes associated with hernia.
* Most patients with inguinal hernia describe a vague feeling of pressure or
discomfort, usually late in the day, associated with standing or working.
It is associated with the feeling of a bulge and goes away when the patient
lies down and the hernia reduces.
* Patients with an indirect hernia may complain of a ‘burning’ discomfort.
This is the result of stretching of the peritoneal sac. Once the sac has
stretched fully, the pain dissipates.
* Chronic incarceration of a hernia, particularly if it consists of omentum,
frequently does not cause any discomfort.
* Sharp, severe, or visceral pain which is present when the hernia is prominent
and goes away when the hernia is reduced suggests incarcerating bowel and
urgent need for repair.
* Sharp pain in the groin that starts as the result of lifting or straining
and is felt during activities such as walking, bending, lifting is MOST OFTEN
the result of myofascial strain. If there is no bulge, there is no hernia.
* Risks of incarceration/strangulation (“rupture”) are generally exaggerated
in the public mind, especially in patients with small hernias.
* Occasionally a patient will come in who has groin pain from an incipient
hernia (burning pain from stretching peritoneum) which has not yet become
palpable. There is no contraindication to observing such a patient and having
him/her return in 3 months or 6 months for re-examination, or when a bulge develops.
Examining Patients for Inguinal Hernia
Position of patient
* The patient should be standing during examination.
Inspection
* A visible bulge or asymmetry is present in the region of the inguinal canal.
* Measure the diameter of the bulge (in centimeters).
* Does it extend into the scrotum?
Palpation
* Palpate the abdominal wall along and directly over the inguinal canal from
internal to external ring.
* The internal ring can be consistently and reliably be found midway between
the anterior superior iliac spine and the upper margin of the pubic bone.
* Invagination of the scrotum and attempts to insert a finger into the external
ring or inguinal canal itself is rarely necessary, always uncomfortable, and
frequently misleading. It is helpful only in over obese patients in whom external
palpation is rendered misleading by overlying fat.
* If a bulge is present, does it reduce?
* If a bulge is present, does it change when the patient strains or coughs?
* If a bulge is not present, does one become palpable when the patient strains or
coughs?
Complications may arise post-operation, including rejection of the mesh that is used to repair the hernia. In the event of a mesh rejection, the mesh will very likely need to be removed. Mesh rejection can be detected by obvious, sometimes localised swelling and pain around the mesh area.
Continuous discharge from the scar is likely for a while after the mesh has been removed.
An untreated hernia may complicate by:
•Inflammation
•Irreducibilty
•Obstruction
•Strangulation
•Hydrocele of the hernial sac
•Haemorrhage
•Autoimmune problems.
Table Methods of herni
|
Mesh-free repair |
|
|
Shouldice (1945) |
Open-anterior approach, doubling running suture of the fascia transversalis and doubling suture of the m. obliquus internus to the inguinal ligament |
|
Bassini (1890) |
Open-anterior approach, fixation of the m. obliquus internus, m. transversus abdominus, and the fascia transversalis to the inguinal ligament |
|
McVay (1942) |
Open-anterior approach, fixation of the m. obliquus internus, m. transversus abdominus, and the fascia transversalis to the Coopers ligament, if the caudal margin of the fascia transversalis is absent |
|
Tension-free repair with mesh |
|
|
Lichtenstein (1970) |
Open-anterior approach with mesh, implantation of mesh behind the aponeurosis of the m. obliquus externus (onlay patch) |
|
Stoppa (1968) |
Open-posterior approach with mesh, bilateral hernias |
|
Wantz (1989) |
Open-posterior approach with mesh; unilateral hernia |
|
TIPP (Rives 1965) |
Open-posterior approach, transinguinal preperitoneal meshplasty |
|
TAPP (1991) |
Laparoscopic-posterior approach with mesh, transabdominal preperitoneal meshplasty |
|
TEP (1991) |
Laparoscopic-posterior approach, total extraperitoneal meshplasty |
|
IPOM (1990) |
Laparoscopic-posterior approach with mesh, intraperitoneal onlay meshplasty |
Femoral hernia
Femoral hernias occur just below the inguinal ligament, when abdominal contents pass into the weak area at the posterior wall of the femoral canal. They can be hard to distinguish from the inguinal type (especially when ascending cephalad): however, they generally appear more rounded, and, in contrast to inguinal hernias, there is a strong female preponderance in femoral hernias. The incidence of strangulation in femoral hernias is high. Repair techniques are similar for femoral and inguinal hernia.
Other abdominal/inguinal hernias
Since many organs or parts of organs can herniate through many orifices, it is very difficult to give an exhaustive list of hernias, with all synonyms and eponyms. The above article deals mostly with “visceral hernias”, where the herniating tissue arises within the abdominal cavity. Other hernia types and unusual types of visceral hernias are listed below, in alphabetical order:
•Cooper’s hernia: a femoral hernia with two sacs, the first being in the femoral canal, and the second passing through a defect in the superficial fascia and appearing immediately beneath the skin.
•Epigastric hernia: a hernia through the linea alba above the umbilicus.
•Hiatal hernia: a hernia due to “short oesophagus” – insufficient elongation – stomach is displaced into the thorax
•Littre’s hernia: a hernia involving a Meckel’s diverticulum. It is named after the French anatomist Alexis Littre (1658-1726).
•Lumbar hernia (Bleichner’s Hernia): a hernia in the lumbar region (not to be confused with a lumbar disc hernia), contains the following entities:
•Petit’s hernia: a hernia through Petit’s triangle (inferior lumbar triangle). It is named after French surgeon Jean Louis Petit (1674-1750).
•Grynfeltt’s hernia: a hernia through Grynfeltt-Lesshaft triangle (superior lumbar triangle). It is named after physician Joseph Grynfeltt (1840-1913).
•Obturator hernia: hernia through obturator canal
•Pantaloon hernia: a combined direct and indirect hernia, when the hernial sac protrudes on either side of the inferior epigastric vessels
•Paraesophageal hernia
•Paraumbilical hernia: a type of umbilical hernia occurring in adults
•Perineal hernia: a perineal hernia protrudes through the muscles and fascia of the perineal floor. It may be primary but usually, is acquired following perineal prostatectomy, abdominoperineal resection of the rectum, or pelvic exenteration.
•Properitoneal hernia: rare hernia located directly above the peritoneum, for example, when part of an inguinal hernia projects from the deep inguinal ring to the preperitoneal space.
•Richter’s hernia: a hernia involving only one sidewall of the bowel, which can result in bowel strangulation leading to perforation through ischaemia without causing bowel obstruction or any of its warning signs. It is named after German surgeon August Gottlieb Richter (1742-1812).
•Sliding hernia: occurs when an organ drags along part of the peritoneum, or, in other words, the organ is part of the hernia sac. The colon and the urinary bladder are often involved. The term also frequently refers to sliding hernias of the stomach.
•Sciatic hernia: this hernia in the greater sciatic foramen most commonly presents as an uncomfortable mass in the gluteal area. Bowel obstruction may also occur. This type of hernia is only a rare cause of sciatic neuralgia.
•Spigelian hernia, also known as spontaneous lateral ventral hernia
•Sports hernia: a hernia characterized by chronic groin pain in athletes and a dilated superficial ring of the inguinal canal.
•Velpeau hernia: a hernia in the groin in front of the femoral blood vessels
Amyand’s Hernia: containing the appendix vermiformis within the hernia sac
Diaphragmatic hernia
Higher in the abdomen, an (internal) “diaphragmatic hernia” results when part of the stomach or intestine protrudes into the chest cavity through a defect in the diaphragm.
A hiatus hernia is a particular variant of this type, in which the normal passageway through which the esophagus meets the stomach (esophageal hiatus) serves as a functional “defect”, allowing part of the stomach to (periodically) “herniate” into the chest. Hiatus hernias may be either “”sliding”,” in which the gastroesophageal junction itself slides through the defect into the chest, or non-sliding (also known as ”para-esophageal”), in which case the junction remains fixed while another portion of the stomach moves up through the defect. Non-sliding or para-esophageal hernias can be dangerous as they may allow the stomach to rotate and obstruct. Repair is usually advised.
Diagrammatic illustration shows various types of internal hernias: A = paraduodenal, B = foramen of Winslow, C = intersigmoid, D = pericecal, E = transmesenteric, and F = retroanastomotic.
Figure. Drawing (superior view) shows the locations of internal hernias, pouches, and fossae of the pelvic cavity in a female patient. H = supravesical hernia, I = hernia through the broad ligament, 1 = vesicouterine pouch, 2 = Douglas (rectouterine) pouch, 3 = perirectal fossa.
A congenital diaphragmatic hernia is a distinct problem, occurring in up to
General Clinical Findings
Clinically, internal hernias can be asymptomatic or cause significant discomfort ranging from constant vague epigastric pain to intermittent colicky periumbilical pain. Additional symptoms include nausea, vomiting (especially after a large meal), and recurrent intestinal obstruction. Symptom severity relates to the duration and reducibility of the hernia and the presence or absence of incarceration and strangulation. These symptoms may be altered or relieved by changes in patient position. Because of the propensity of these hernias to spontaneously reduce, patients are best imaged when they are symptomatic
TABLE: Clinical and Imaging Findings for Internal Hernias
Note—LUQ = left upper quadrant, IMV = inferior mesenteric vein, SMA = superior mesenteric artery, RLQ = right lower quadrant, IVC = inferior vena cava. aIncidence for first six types from Meyers, which are historic data but only major source currently available. Incidence for these first six types of internal hernias totals only 93% because perivesical hernias reported are not true internal hernias, so they were not included in this review bProbably more transmesenteric and retroanastomotic internal hernias currently because of number of liver transplant and gastric bypass operations being performed throughout the United States during past decade. The 5% refers to the incidence after Roux loops used during surgery for reasons other than liver transplantation or gastric bypass |
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Prevention of hernias
In many cases hernias are due to age and your genetic propensity. There is not much you can do about that. However, there are some factors which can raise your risks of developing a hernia.
Heavy lifting – heavy lifting is known to cause hernias.
Smoking and coughing – coughing, especially persistent coughing can cause a hernia to develop. Anything you can do to reduce or eliminate your cough will help enormously. If you smoke, try to give up, or at least cut down. Quitting smoking will prevent several other serious diseases. Studies indicate that your chances of succeeding in giving up smoking are significantly greater if you seek help from your GP (primary care physician) and join a support group.
Nutrition – a diet that is high in fiber will help your bowel movements. Constipation, especially if the person is often constipated, greatly increases hernia risk. Eat plenty of fruits, vegetables and wholegrains. Make sure you drink plenty of fluids.31
Obesity – being overweight can increase your risk of developing a hernia considerably. The more overweight you are, the higher your risk. Try to lose weight. Make sure, if you are obese, that you lose weight gradually. It is always advisable to seek professional help before you embark on any exercise program. Ask your doctor for advice on diet and exercise.
Anal fissure
Introduction
An anal fissure is a linear tear in the skin of the distal anal canal below the dentate line. It is a common condition affecting all age groups but particularly common in young adults; men and women are equally affected. The classical symptoms are of anal pain during or after defaecation and the passage of bright red blood per anus. The pain is often severe and may last for a few minutes or for several hours after defaecation. Bleeding from an anal fissure is usually modest and any significant loss of fresh blood may be from another source such as haemorrhoids as these two conditions commonly co-exist. Pruritus ani may also accompany anal fissures. Symptoms from fissures cause considerable discomfort and reduction in quality of life.
On examination the fissure may be apparent as a linear or pear-shaped split in the lining of the distal anal canal as the buttocks are parted, but there is often marked spasm of the anal canal which obscures the view. The combination of spasm and pain often precludes a digital rectal or proctoscopic examination but a typical history supported by clinical findings of anal spasm makes the diagnosis of anal fissure highly likely. If visualized an acute fissure will have sharply demarcated fresh mucosal edges and there may be granulation tissue in its base. With increasing chronicity there is induration of the margins of the fissure and a distinct lack of granulation tissue; horizontal fibres of the internal sphincter muscle may be seen in the base of the mucosal defect and secondary changes such as a sentinel skin tag, hypertrophied anal papilla or a degree of anal stenosis may be present.
The majority of anal fissures are probably acute and resolve either spontaneously or with simple dietary modification to increase fibre and laxatives where appropriate. The distinction between acute and chronic fissures is an arbitrary one, but fissures failing to heal within 6 weeks despite straightforward measures are generally designated as “chronic”. Although a proportion (less than 10%) of these chronic fissures will eventually resolve with conservative measures, most will require further intervention in order to heal. Fissures are usually single and posterior midline fissures are most common, but 10% of women and 1% of men have fissures in the anterior midline. Women who develop symptoms after childbirth usually have anterior fissures. Multiple fissures or those in a lateral position on the anal margin raise suspicion as there may be underlying inflammatory bowel disease, syphilis, or immunosuppression including HIV infection. However, it is important to recognize that most fissures arising in patients with inflammatory bowel disease are posterior and are also painful in at least one half of cases. Similarly, fissures that are resistant to treatment should prompt further investigation.
Pathogenesis
The pathogenesis of chronic anal fissure is poorly understood. In the past it was believed that the passage of a hard stool traumatized the anal mucosa. Although a plausible initiating factor, this does not explain why only one in four patients reports constipation and the onset of symptoms follows a bout of diarrhoea in 4 to 7% of instances. A dietary association may exist as people taking a diet low in fibre appear to be at increased risk of developing anal fissures.
There may be more than one pathogenic process leading to the development of chronic fissures:
Trauma during pregnancy
Up to 11% of patients with chronic anal fissures develop symptoms following childbirth and the risk increases with traumatic deliveries. Shearing forces from the foetal head on the anal mucosa may have significance in this group of patients. Postpartum, the anal mucosa may become tethered to the underlying muscle thereby rendering it more susceptible to trauma, and this has also been cited as a possible aetiological factor. Both theories on the mechanism of trauma are speculative and difficult to substantiate.
Anal spasm
The resting pressure in the anal canal is largely a function of the internal sphincter which is in a continuous state of partial contraction that is both nerve-mediated via α-adrenergic pathways and due to inherent myogenic tone. Relaxation of this smooth muscle occurs automatically in response to rectal distension, the so-called rectoanal inhibitory reflex. Acetylcholine via muscarinic receptors and β-adrenergic stimulation both mediate relaxation in isolated strips of internal sphincter. The same effect is observed in response to electrical field stimulation via a non-adrenergic, non-cholinergic neuronal pathway and nitric oxide has been demonstrated to be the neurotransmitter responsible.
Patients with chronic anal fissure generally have raised resting anal pressures due to hypertonicity of the internal anal sphincter, but the mechanisms of this are unclear. A long high pressure zone in the anal canal and ultraslow waves are seen more commonly in fissure patients than in healthy controls and there may be an abnormal rectoanal inhibitory reflex. The administration of pharmacological preparations that relax the internal anal sphincter, effectively reducing anal pressure, can lead to healing of chronic fissures. However, this effect on the muscle is reversible and resting pressures appear to return to original values once treatment is discontinued, even after the fissure has healed. These findings suggest that the anal spasm may predate the onset of the fissure. The internal sphincter spasm is probably not secondary to pain as the application of topical local anaesthetic to a fissure alleviates the pain but does not reduce the anal spasm.
In the presence of chronic anal fissure, the internal anal sphincter has been shown on histological examination to be fibrotic both in the base of the fissure and at remote sites. This finding has led to the suggestion of an underlying inflammatory process where myositis occurs early on in the condition with subsequent fibrosis. The fibrosis may in fact be secondary to ischaemia. However, despite various theories, the cause of the spasm associated with anal fissure remains obscure.
Local ischaemia
Chronic anal fissure has been described as an ischaemic ulcer. The distal anal canal receives its blood supply from the inferior rectal arteries, branches of the internal pudendal arteries. In cadaveric studies, angiography of the inferior rectal vessels has demonstrated a paucity of arterioles at the posterior commissure in 85% of cases, the site for which fissures appear to have a predilection. Blood flow to the distal anal canal, measured by laser doppler flowmetry is inversely correlated with anal pressure and increases as pressures fall. General anaesthesia, sphincterotomy, and the application of topical glyceryl trinitrate (GTN) ointment all lower resting anal pressure and simultaneously increase the local tissue perfusion in anal fissure. As lateral internal sphincterotomy and topical GTN successfully heal 90% and 70% of fissures respectively, the blood supply prior to treatment may have been inadequate for healing to occur. It is possible that blood vessels traversing the hypertonic internal sphincter en route to the anal mucosa may be compressed, resulting in compromised perfusion of the anal mucosa and fissure. Since the spasm in the anal canal in patients with chronic anal fissures appears to predate the fissure, this would support an ischaemic basis for chronic anal fissure, and imply that some people may be predisposed towards developing anal fissures.
Treatment
Acute fissure
Over 90% of acute anal fissures will heal spontaneously or with simple measures. A diet high in fibre (with an increased intake of water) is recommended, laxatives may be required to soften constipated stool, while warm sitz baths may offer symptomatic relief. Topical preparations of hydrocortisone and local anaesthetics have been compared with dietary bran supplements and probably confer no added benefit. These preparations may have adverse effects and a patient in one study found that topical steroid precipitated extensive anal herpes, previously occult. There is evidence that local anaesthetic significantly delays healing compared with bran supplements or topical hydrocortisone and may also lead to skin sensitisation. The use of lubricated anal dilators prior to defaecation gained popularity for a period of time, but fell out of favour as studies reported a high relapse rate among those initially cured. The majority of fissures responding to this treatment in the first instance were acute fissures.
Chronic fissure
A small number of chronic fissures heal without intervention but the vast majority do not. The treatment of chronic anal fissure is directed at reducing the spasm of the internal anal sphincter and hence, anal canal pressure. Traditionally this has been achieved surgically by sphincterotomy, where part of the internal anal sphincter is divided, but more recently various pharmacological agents have been shown to lower resting anal pressure and promote healing.
The recognition of nitric oxide as a neurotransmitter mediating relaxation of the internal anal sphincter has led to the use of exogenous nitric oxide from drug donors in the treatment of chronic anal fissure. Various preparations of isosorbide mononitrate, isosorbide dinitrate and glyceryl trinitrate have been shown to successfully heal chronic fissures.
Topical glyceryl trinitrate (GTN) ointment applied to the anal verge has now gained acceptance in many centers as an effective first line treatment for chronic fissures. GTN is metabolized at a cellular level to release nitric oxide which in turn mediates relaxation of the internal sphincter via the guanylate cyclase pathway. This effect has been coined a “chemical sphincterotomy”, and is reversed once treatment is stopped. The dose of GTN delivered depends upon the concentration and the volume of ointment applied. A regime using approximately 500 mg of 0.2% GTN ointment, applied twice daily to the anal verge, has been shown to heal 70 to 80% of chronic fissures. Fifty per cent of patients using GTN develop a headache which may be sufficiently severe to warrant discontinuing the drug. Anal pressures appear to return to pre-treatment levels within 3 months of GTN being stopped even after the fissure has healed and there is therefore the possibility of the fissure recurring. The long term follow up, by questionnaire, of 41 patients included in a randomized controlled trial using 0.2% GTN for chronic fissure reported a recurrence of symptoms in 11 patients within a median of 2 years; 8 resolved with further GTN and 3 underwent sphincterotomy. This illustrates that almost 93% of patients in the study avoided surgery for their fissures and demonstrated that topical GTN may be used effectively should fissures recur.
Botulinum toxin has also been used to treat chronic anal fissures. It is a potent neurotoxin, binding to presynaptic cholinergic nerve terminals and inhibiting the release of acetylcholine. Muscle paralysis occurs within hours and the effect remains for 3–4 months, until there has been axonal regeneration with the formation of new nerve terminals. There is some confusion in the literature about the optimal site of injection of the toxin. Studies including small numbers of patients where the toxin has been injected into the external anal sphincter have reported healing rates of over 80%. The internal sphincter has also been injected with botulinum toxin causing reduction in resting anal pressure and healing of 70–80% of fissures. In the external anal sphincter the toxin probably causes relaxation by inhibiting the release of acetylcholine from nerve terminals. However, acetylcholine mediates relaxation in the smooth muscle of the internal sphincter and so blockade of its release by botulinum toxin ought to increase anal tone. The mechanism by which botulinum reduces the tone in internal sphincter remains unclear. The treatment itself has the advantage of having a prolonged effect that is nonetheless reversible, avoiding the risk of permanent injury to the anal sphincter mechanism. On the other hand it is invasive and associated with complications such as perianal haematoma, sepsis, and pain during injection of the toxin. It is somewhat difficult to be certain as to precisely where the toxin has been injected and patients may find the procedure uncomfortable.
Pharmacological agents are employed as the first line treatment for chronic fissures in many centers, but failure of medical therapy in the presence of persistent symptoms warrants surgical intervention. The surgical approaches to chronic fissures have included anal stretch, posterior sphincterotomy through the base of the fissure later replaced by lateral internal sphincterotomy, and most recently advancement flaps to cover the mucosal defect. Anal stretch is a nonstandardized procedure and the resultant disruption to the sphincter mechanism, as demonstrated by endoanal ultrasonography may be significant and lead to permanent damage to the sphincter mechanism. Incontinence for flatus and soiling is reported in up to 39%, up to 16% have faecal incontinence and recurrence of fissure following anal stretch occurs in as many as 56.5%.
Sphincterotomy was initially performed at the site of the fissure usually in the posterior midline, and the fibres of the internal sphincter were divided in its base. However, posterior sphincterotomy wounds take noticeably longer to heal than lateral sphincterotomy sites, sepsis is more common in the former, and guttering of the posterior midline scar may occur in up to 28%. This so-called keyhole deformity sometimes leads to imperfect closure of the anal canal or trapping of faeces with resultant soiling.
Posterior sphincterotomy was then replaced by lateral internal sphincterotomy either performed using a closed technique or under direct vision, under local or general anaesthesia. Studies have shown the results of the open and closed techniques to be similar. The type of anaesthesia probably makes little difference to healing. The ideal length of the lateral sphincterotomy is undecided but most agree that it is wise to limit the incision to the length of the fissure. This procedure is complicated by varying degrees of incontinence in up to 35% of patients, that is more frequently encountered in women. One study using endosonography to assess the internal sphincter postoperatively revealed that the sphincterotomy was often more extensive than appreciated at the time of operation, particularly in female patients. To avoid complication in women with fissures in the puerperium, who may have sustained significant damage to the anal sphincter, for example severe tears or episiotomy, it is prudent to assess the integrity of the anal sphincter using anorectal ultrasound prior to surgical intervention. Where the internal sphincter is already compromised it may be more appropriate to perform an anal advancement flap to repair the mucosal defect rather than to risk impairing anal continence through iatrogenic injury to the sphincter.
Until the advent of topical GTN therapy, lateral internal sphincterotomy was the “gold standard” treatment for chronic fissures. In recent years topical 0.2% GTN ointment has become a useful first line pharmacological treatment. “Chemical sphincterotomy” is particularly suitable in patients with associated inflammatory bowel disease where sphincterotomy for anal fissure is generally contraindicated. Where pharmacological therapy fails lateral internal sphincterotomy is the surgical treatment of choice and the results are satisfactory so long as patients are carefully selected.
The future
Recent studies have demonstrated that there is a role for pharmacological agents in the treatment of chronic anal fissure. Preliminary data using calcium channel antagonists in volunteers and in patients with chronic anal fissure indicate that these drugs reduce resting anal pressure but their precise role in the treatment of fissures is yet to be determined. Bethanacol, a parasympathomimetic drug, has also been shown to lower pressures in the anal canal and by the same token shows similar promise. An obvious advantage of these alternative treatments is that they may be effective in the 30% of cases where GTN fails as they act via different pathways, so that ultimately surgery is avoided. In addition, there have not been significant associated side effects reported but patient selection is important. Calcium channel blockers, for example, may have deleterious effects in patients with existing cardiac abnormalities and can interact with other drugs. The precise role for these drugs in the treatment of chronic anal fissure remains to be seen based upon future studies.
Haemorrhoids
Haemorrhoids are common in men and women. About half of the population has haemorrhoids by the age of 50. It has been estimated that 58% of people over 40 years have haemorrhoids in the
Classification
In general, there are two types of haemorrhoids: internal and external haemorrhoids.
Internal haemorrhoids are classified as:
There is no similar classification for external haemorrhoids. They are considered to be swelling of the skin and anoderm around the anus. Skin tags are later stages of external haemorrhoids.
Pathogenesis
Haemorrhoids are swollen blood vessels in and around the anus and lower rectum that stretch under pressure. Increased pressure and swelling may result from straining to move the bowel. Other contributing factors included pregnancy, heredity, aging, and chronic constipation or diarrhea.
Symptoms
The following physical signs may accompany haemorrhoids: bleeding, prolapse, pain, itching, rectal dysfunction, soiling.
Differential diagnosis
Differential diagnosis of haemorrhoids includes anal tags, fibrous anal polyp, anal fissure, dermatitis, perianal haematoma, rectal prolapse, and rectal tumor.
Treatment options for haemorrhoids include
- Rubber band ligation
- Infrared photocoagulation
- Bipolar diathermy
- Sclerotherapy
- Cryotherapy
- Open Haemorrhoidectomy
- Closed haemorrhoidectomy
- Anal dilation
- Pile stitching
- Stapled haemorrhoidectomy
Treatment modalities for haemorrhoids
A more conservative approach is the first line treatment for haemorrhoids in most instances. There are several treatment options available: Rubber band ligation (RBL), infrared coagulation (IRC), sclerotherapy, anal dilatation, bipolar coagulation, and direct current coagulation. Most studies have investigated the effect of rubber band ligation. Single versus multiple rubber band ligation was investigated in two randomized studies. There was no difference in rebanding rate, complications, discomfort or pain. However, triple RBL was more cost-effective.
In comparison to sclerotherapy, RBL may cause more treatment discomfort, but RBL is considered the best treatment for 2° haemorrhoids. Photo- or Infrared-Coagulation may have less side effects (bleeding, pain) than RBL. Patients were often more satisfied with the treatment success of RBL. Recurrence of prolapse was more often observed after IRC treatment. When comparing sclerotherapy with photocoagulation both therapy modalities were considered equivalent; however, after photocoagulation repeated therapy was necessary. Current coagulation and bipolar coagulation did not demonstrate any improvement when compared to other treatment modalities. A recent study has investigated the use of Kamillosan ointment RBL plus anal dilation plus vaseline and showed superiority to RBL alone and RBL plus anal dilatation. A comparison of RBL with anal dilation has not detected a difference in outcome. In a recent meta-analysis of hemorrhoidal treatments it was concluded that Rubber band ligation is the initial mode of therapy for 1° to 3° haemorrhoids.
Table I Randomized studies comparing rubber band ligation, sclerotherapy, and photocoagulation
|
Author |
Year |
Technique |
Results |
|
Greca |
1981 |
RBL Sclerotherapy |
Repeated treatment was necessary after sclerotherapy. 2/3 of patients with 3° haemorrhoids required additional therapy; the authors concluded that RBL and sclerotherapy provide similar results, but RBL is more liable to complications. |
|
Leicester |
1981 |
IRC versus sclerotherapy ionprolapsing haemorrhoids and IRC versus RBL in prolapsing haemorrhoids |
No complications occurred. Significantly fewer patients experienced pain after IRC. |
|
Sim |
1981 |
RBL Sclerotherapy |
Prolapse was more often with sclerotherapy. RBL caused more treatment discomfort, but it is considered an effective treatment in 1° and 2° haemorrhoids. |
|
Ambrose |
1983 |
RBL Photocoagulation |
Side effects are more common after RBL (bleeding, pain); after photocoagulation further treatment is ofteecessary; Patients were more satisfied with RBL |
|
Khubchandani |
1983 |
Single RBL Multiple RBL |
There was no significant difference in morbidity or complications. |
|
Templeton |
1983 |
IRC RBL |
The incidence of side effects was higher in RBL patients. The number of treatments did not differ between groups. However, IRC was faster than RBL. |
|
Umpleby |
1983 |
Anal dilation RBL |
There was no difference in outcome observed. |
|
Ambrose |
1985 |
Photocoagulation Sclerotherapy |
Results of sclerotherapy are comparable to photocoagulation; repeated therapy necessary after photocoagulation |
|
Gartell |
1985 |
RBL Phenol injection |
RBL produced significantly more successful outcomes, symptoms tended to respond favorably to RBL, complications were minimal. It was concluded that RBL is the better treatment for 2° haemorrhoids. |
|
Poon |
1986 |
RBL Triple RBL |
There was no difference in rebanding rate, discomfort, pain or complication rates. Triple RBL, however, was more cost-effective. |
|
Walker |
1990 |
IRC Sclerotherapy RBL |
Nonprolapsing haemorrhoids were better treated by IRC compared to sclerotherapy. With regard to prolapsing haemorrhoids there was no difference after IRC or sclerotherapy. Recurrence of prolapse was more often seen after IRC than RBL; IRC was less painful than sclerotherapy. |
|
Dennison |
1990 |
IRC Bipolar coagulation |
There was no difference in complication rate or number of treatments. |
|
Varma |
1991 |
Sclerotherapy Current coagulation |
Sclerotherapy produced a better early cure rate. |
|
Forster |
1996 |
RBL RBL+anal dilation Kamillosan ointment RBL + anal dilation + vaseline |
Number of treatments was significantly reduced as was the number of ligatures after Kamillosan ointment RBL |
RBL= Rubber Band Ligation; IRC= Infrared Coagulation
Operative haemorrhoidectomy techniques have been compared in randomized studies since 1979. Anal dilation may reduce anal pressure significantly. However, in most studies anal dilation gave either poor results or anal dilation was associated with faecal incontinence. The results after sphincterotomy are controversial. Sphincterotomy has been used as additional therapy in two randomized studies with good results; however, in a recent study there were more cases of anal incontinence reported after sphincterotomy. Submucosal haemorrhoidectomy produced as similar outcome when compared to ligation/excision haemorrhoidectomy. Although there was no difference in pain diathermy excision without ligation was associated with less postoperative analgesic requirement compared to conventional scissors excision/ligation. Milligan-Morgan (MM) operation and diathermy had less pain and a faster canalization than closed haemorrhoidectomy (
IRandomized studies comparing open and closed haemorrhoidectomy, diathermy, anal dilation, and sphincterotomy
|
Author |
Year |
Technique |
Results |
|
Keighley |
1979 |
Anal dilation vs sphincterotomy vs high fibre diet in high anal pressure RBL vs cryosurgery vs high fibre diet in lower anal pressure |
Anal dilation was the only treatment that resulted in a significant reduction of anal pressure. More patients were improved by RBL. Patients with excessive activity of the internal sphincter are best treated by anal dilation. |
|
Murie (61) |
1980 |
RBL vs haemorrhoidectomy |
Haemorrhoidectomy relieved more patients after 1 year than RBL. However, haemorrhoidectomy caused pain in all patients, whereas RBL did not. Mean time off work was shorter after RBL. |
|
Cheng |
1981 |
Injection sclerotherapy vs RBL vs anal dilation vs haemorrhoidectomy |
IST was the least effective treatment Haemorrhoidectomy caused pain in all patients, RBL was painless in most patients RBL is the most appropriate method for 2° haemorrhoids |
|
Greca (62) |
1981 |
Anal stretch with continued dilation vs anal stretch without continuous dilation |
Continuous dilation improves the results of anal stretch |
|
Murie (63) |
1982 |
RBL vs haemorrhoidectomy |
Anal pain, pruritus, soiling were improved by both techniques. Haemorrhoidectomy is more successful in treating 3° haemorrhoids. |
|
O’Callaghan (64) |
1982 |
Cryosurgery vs MM |
Cryosurgery gave results similar to MM in patients with prolapsing piles with fewer complications and less time in hospital. |
|
Mortensen |
1987 |
MM vs MM + anal dilation |
Combination of MM with anal dilation may increase the risk of anal incontinence. |
|
Roe |
1987 |
Submucosal haemorrhoidectomy vs Ligation/excision haemorrhoidectomy |
No differences in pain and function found |
|
Asfar |
1988 |
Anal stretch + haemorrhoidectomy vs sphincterotomy + haemorrhoidectomy |
Routine sphincterotomy reduces pain, faecal soiling, urinary retention |
|
Rasmussen (65) |
1991 |
Emergency haemorrhoidectomy vs incision and banding |
Less pain after incision and banding, earlier discharge after incision and banding |
|
Hiltunen |
1992 |
Anal dilation vs lateral subcutaneous sphincterotomy vs haemorrhoidectomy |
Both anal dilation and sphincterotomy gave poor results in 25 % of patients |
|
Seow-Choen |
1992 |
Conventional scissors excision/ligation vs diathermy excision without ligation |
No differences in pain, but less analgesics after diathermy; diathermy is faster and causes less bleeding. |
|
Senagore (66) |
1993 |
Cold scalpel vs Nd: YAG laser |
More expenses and inflammation after laser treatment |
|
Yang (67) |
1993 |
Bipolar coagulation vs direct current coagulation |
Direct current causes more procedural pain. Postreatment rectal ulcerations occur more often after bipolar coagulation |
|
Randall (68) |
1994 |
Bipolar vs direct current coagulation |
Rebleeding is less frequent after direct current treatment, which produced fewer complications. |
|
Chia (69) |
1995 |
CO2 laser vs conventional haemorrhoidectomy |
Laser is associated with reduced postoperative analgesic requirement. |
|
Seow-Choen (70) |
1995 |
Modified radical haemorrhoidectomy vs four piles haemorrhoidectomy |
Results were less good after modified radical haemorrhoidectomy |
|
Mathai |
1996 |
Haemorrhoidectomy vs haemorrhoidectomy + lat. Int. sphincterotomy |
2/17 patients had incontinence problems after lateral sphincterotomy |
|
Bassi |
1997 |
Closed haemorrhoidectomy (Ferguson) vs Milligan Morgan vs diathermy haemorrhoidectomy |
Faster canalization and minor pain after MM and diathermy. No difference in postoperative hemorrhage between MM and diathermy |
|
Ho |
1997 |
Open haemorrhoidectomy vs closed haemorrhoidectomy |
No difference in pain, analgesic requirements, length of hospital stays. Complete wound healing took significantly longer after closed haemorrhoidectomy |
|
Ibrahim |
1998 |
Scissors closed haemorrhoidectomy vs diathermy closed haemorrhoidectomy |
No difference in pain Diathermy seems to require les postoperative analgesic medication except in the first 24 h. |
|
Carapeti |
1999 |
Open haemorrhoidectomy vs closed day case haemorrhoidectomy |
No difference in pain, analgesia, complications. |
|
Cheetham |
2000 |
Stapled haemorrhoidectomy vs standard haemorrhoidectomy |
Persistent pain after stapled haemorrhoidectomy lead to suspension of the trial |
|
Galizia |
2000 |
Lateral sphincterotomy + haemorrhoidectomy vs haemorrhoidectomy alone |
Patients with lateral internal sphincterotomy had a better postoperative outcome |
|
Konsten |
2000 |
Anal dilation (Lord’s) vs haemorrhoidectomy |
Anal dilation is associated with a high percentage of fecal incontinence |
|
Mehigan |
2000 |
Stapled haemorrhoidectomy vs MM |
Shorter anaesthesia time, less pain, and faster return to normal activity after stapled haemorrhoidectomy |
|
Rowsell |
2000 |
Stapled haemorrhoidectomy vs conventional haemorrhoidectomy |
Less pain, less hospital stay, faster return to normal activities after stapled haemorrhoidectomy |
RBL Rubber Band Ligation
In summary, rubber band ligation is the treatment of choice for 1° to 3° haemorrhoids. Other treatment modalities may be used as adjunct therapy. In case rubber band ligation is not successful or 3° to 4° haemorrhoids operative haemorrhoidectomy is indicated. Open or closed haemorrhoidectomy show similar results. Diathermy excision of haemorrhoids seems to have the advantage of less analgesic requirement and faster procedure time. It is too early to announce a recommendation for stapled haemorrhoidectomy, although there are two randomized studies with promising results. However, the follow up of these studies is too short and there are alarming reports on pain and complications with regard to the use of stapled haemorrhoidectomy (Grade A-C).
Additional treatment for haemorrhoids
Haemorrhoid treatment, especially haemorrhoidectomy or RBL, is associated with treatment discomfort. Several randomized studies were performed to reduce the pain and analgesic requirement after haemorrhoid treatment. Lactulose given four days preoperatively and high fiber diet may effectively reduce pain. Special dressings may help to reduce pain at the time of removal of rectal packing. Locally injected bupivacaine had no effect on pain or analgesic requirement after haemorrhoidectomy. The effect on pain after RBL is only short-term. Wound infiltration with lignocaine prolongs the postoperative analgesia after haemorrhoidectomy with spinal anaesthesia. Topical applied anaesthesia followed by local anesthetic injection, however, may be as effective as general anaesthesia. Transdermal fentanyl injection reduces the postoperative requirement of narcotics and may thereby improve the transition to outpatient management. A local ischiorectal fossa block decreased postoperative pain after haemorrhoidectomy. Similar results were achieved, when a transcutaneous electrical nerve stimulation was applied after haemorrhoidectomy; however, further studies need to confirm this result and the clinical feasibility. Ketorolac has been investigated in pain control after haemorrhoidectomy and anorectal surgery. Pain and analgesic requirements were significantly reduced, patients were more satisfied and there was no urinary retention observed. A comparison of 2% lignocaine, 0.5% bupivacaine, 2% lignocaine + morphine sulfate, morphine sulfate and no injection demonstrated that postoperative analgesic requirement was best reduced by morphine and morphine + lignocaine resulting in a longer analgesic period. However, the number of patients requiring postoperative opiates was not affected by any treatment modality. Other analgesic compounds investigated were nimesilide versus naproxen; both drugs were equally effective in reducing pain and edema after haemorrhoidectomy. An effective pain treatment may be the addition of metronidazole three times daily for seven days. Anal sphincter relaxation by trimebutine was not effective in reducing postoperative pain, despite a 35% reduction in anal pressure. The use of cortisone has reduced postoperative pain, but only during the first 24 hours.
Urinary retention is a possible complication of haemorrhoidectomy. It has been suggested that patient’s anxiety may induce urinary retention. However, anxiolytic treatment (midazolam) had no effect on urinary retention.
Bleeding, another complication after haemorrhoid treatment may be influenced by high fibre diet or micronized flavonoids. Dressing does not influence postoperative haemorrhage.
In summary, there is evidence that pretreatment with metronidazole, lactulose and high-fibre diet may help to overcome some of the side effects of haemorrhoid operations. Local injection of anaesthetics may prolong the analgesic time postoperatively.
In conclusion, randomized studies in haemorrhoid treatment have been performed already more than 20 years ago, adding evidence to haemorrhoid treatment. Unfortunately many studies do not classify the haemorrhoids treated. Follow-up often is short and the number of studied patients small. Nevertheless, haemorrhoid treatment appears to be based on firm evidence when compared to other surgical diseases.
Anal abscess and fistula
Perianal abscesses usually develop from the proctodeal glands which originate from the intersphincteric plane and perforate the internal sphincter with their duct. The abscesses may break through into the anal canal and resolve completely, but they can also spread by a submucosal, intersphincteric or transsphincteric route and develop into fistulae.
Classification and pathological anatomy
A review of the literature shows a wide variation in classification and nomenclature of perianal fistulae and abscesses. Therefore, in this paper the classification based on A. Parks is used. According to this, the classification of anorectal abscesses and fistulae is given by their location
a. Typical location and extent of anorectal abscess and fistula: 1 intersphincteric, 2 transsphincteric (ischiorectal), 3 extrasphincteric, 4 submucosal. b. Therapy: abscess incision and incision/excision of fistula.
Superficial infections may lead to submucosal or subcutaneous abscesses. If the abscess perforates the external sphincter, an ischiorectal abscess develops. If the intersphincteric abscess spreads cranially beyond the levator muscles, a pelvirectal abscess results. Semicircular and, mostly, posterior progression of the infection leads to a horseshoe abscess or fistula formation.
A fistula develops as the result of spontaneous perforation of the abscess, or of surgical incision. If the external and internal (anal) ostium can be verified by examination, the so called complete fistula will be treated as later shown. An incomplete fistula has only one orifice.
Symptoms
Abscess
Superficial abscesses (subcutaneous, submucosal, ischiorectal abscesses) show typical symptoms such as pain, swelling, tenderness, fever. Due to their anatomic location, they often cause discomfort on walking and sitting. Usually the vicinity to the anal canal causes painful defecation.
Deep abscesses (intermuscular, pelvirectal) often lack typical symptoms. Diffuse pelvic pain and raised body temperature are found occasionally.
Besides physical examination, including rectal-digital examination, CT, MRI or endosonography have proven to give information about deeper abscesses (grade B and C).
Fistulae
The symptoms of perianal fistulae depend on the severity of inflammation. Bland fistulae may excrete pus, sometimes serous fluid and rarely feces, leading to pruritus ani, itching and skin maceration. Severe symptoms occur only occasionally, when spontaneous closure of the fistula leads to recurrent abscess formation.
Diagnosis
Diagnostic procedures are aimed at the exact localization of the abscess or fistula in order to perform adequate surgical therapy leading to full functional recovery of the patient.
Abscess
The clinical diagnosis is made by inspection and palpation. If possible, rectoscopy/proctoscopy should be performed, although in the case of an acute abscess this may be too painful. For deeper abscesses imaging procedures may be employed. Transanal endosonography and MIR have shown good results (grade B and C).
Fistulae
Besides obligatory recto- and proctoscopy the diagnosis of fistulae may include the instillation of methylene blue solution. The course of the fistulae can be identified with various probes.
Occasionally, endosonography, if necessary with contrast medium, and lately MRI have been helpful to establish the appropriate therapeutic strategy.
Some authors advocate preoperative manometry in order to choose the therapeutic management according to the risk of incontinence (grade B).
Therapy
Abscesses
Anorectal abscesses are incised and laid open on the shortest route. The location of the abscess determines the surgical approach. The operation should be performed under regional or general anesthesia.
In subcutaneous or submucosal abscesses located within the outer anal canal, a skin excision should be performed to create free drainage and to prevent early closure of the skin. In perianal abscesses synchronous fistulotomy seems not to impair functional outcome (grade C).
Intermuscular abscesses can be drained transanally to the inside of the anal canal. The abscess cavity is opened by incision of the anoderm and the internal sphincter overlying the abscess. Ischiorectal abscesses are opened by a sufficiently large skin incision into the ischiorectal fossa, a synchronous fistulotomy does not seem to be necessary (grade B and C).
Drainage of pelvirectal abscesses can also be performed perineally, provided the levators are opened wide enough to assure adequate drainage.
In a pelvirectal abscess with a fistula towards the rectum, the drainage may also be performed transanally.
Anal fistula
Fistulae should be classified prior to surgery, since the crucial point for the right surgical approach and functional results is the exact preoperative localization of the tract of the fistula (grade B and C). Fistulotomy of subcutaneous or submucosal fistulae can be performed with a probe. No extra excision of the fistulous tract is necessary, the wound can remain open for secondary healing. Exact localization of the inner opening of the fistula can be attained by endosonography or by probes. Alternatively, some authors describe techniques using primary closure or marsupialization of the wound edges to the fistula ground to obtain better functional results and/or earlier healing (grade B).
If less than the distal two thirds of the internal sphincter muscle are involved the respective distal sphincter parts and the anoderm can be cut as previously described for subcutaneous fistulae. Impaired continence is unlikely to develop. The wound should also remain open for secondary healing. Recent literature suggests an approach which preserves the sphincter better, because follow-up studies after surgery for fistula-in-ano often show a decreased sphincter tonus and impaired continence. This observations, combined with EUS findings of occult sphincter damage after fistulotomy with division of the internal sphincter is used as argument for sphincter-preserving procedures (as described for transsphincteric fistulae (grade B and C)).
Transsphincteric fistulae
If more than two thirds of the sphincter muscle are affected, division of the sphincter muscle without loss of continence is unlikely. Therefore, it is recommended not to severe the sphincter muscle. Even if there will be no incontinence at first, physiological aging may cause muscular weakening in the long-term (grade C).
Staged procedures are sometimes necessary. In a first step the fistula is identified and marked with a seton. This may require anesthesia. At the same time, external tracts of the fistula are laid open. If there are no inflammatory changes or if inflamed tissue can be resected, closure of the internal ostium may be achieved by single stitch sutures. More often a second intervention is necessary to excochleate the remaining outer part of the fistula, if excision is not possible. The inner ostium is excised out of the sphincter muscle, the muscle is sutured and the row of sutures is covered by a mucosal advancement flap, which is dissected from the mucosa cephalad to the internal aperture and sutured to the lower margin of the mucosa. Alternatively a full-thickness rectal (wall) advancement flap may be used, showing better results in certain indications (grade B and C).
Sliding flap. a, b. Coring out of all the fistulous tract and anal gland. c. Mobilization of a mucosal flap. d. Closure of muscular gap. e. of the mucosa.
Extrasphincteric fistulae
The cure of extrasphincteric fistulae may also include several surgical procedures. In a first step the outer part of the fistula should be excised. If the internal orifice can be securely identified, the fistula can be closed either using a mucosal or rectal advancement flap or with direct suture protected by a diverting colostomy.
Some authors recommend the use of a cutting seton to avoid surgical division of the sphincter apparatus. The published data show good functional and satisfying results, although the therapy needs a long time (grade C).
Recto-vaginal fistulae
A particular form of fistula is the recto-vaginal fistula. Exact preoperative diagnosis is essential to determine exactly size and localization, to assess the stage of the anal sphincter, and to reveal the cause of the fistula such as Crohnís disease, radiation, obstetric injury, neoplasia, operative trauma. The surgical approach depends on the level of the opening of the fistula into the rectum and into the posterior wall of the vagina.
Recto-vaginal fistulae have to be differentiated from ano-vaginal fistulae which originate from the anal canal distal to the dentate line. Recto-vaginal fistulae are classified according to their location, size, and etiology. Most surgeons arbitrarily classify a fistula as low when it can be repaired from a perineal approach and as high if it can be approached only transabdominally. The size of recto-vaginal fistulae ranges from less than
The timing of the operation is determined by the likelihood of spontaneous or non-operative healing of the fistula. About one half of small recto-vaginal fistulae secondary to obstetric trauma may heal spontaneously, whereas recto-vaginal fistulae due to inflammatory bowel disease and radiation therapy of neoplasia rarely will. For this reason in certain cases a conservative approach for up to six months is recommended, which should be used to improve the patientís general condition.
For high fistulae closing should be performed from an abdominal approach. After mobilizing the rectum the fistula is transsected. Alternatively a low anterior resection of the rectum may become necessary.
Recto-vaginal fistulae opening into the distal suprasphincteric part of the rectum can be treated by a mucosal or rectal advancement flap. This requires a deviation enterostomy or adequate bowel preparation followed by parenteral nutrition.
After dissection of the mucosal flap the fistulous tract is carefully excised from the muscle and the posterior wall of the vagina, followed by suture closure of the muscle. These sutures will be covered by the mucosal flap. The vaginal side of the fistula remains open.
Prior to operation exact evaluation of the sphincter muscle is mandatory. To avoid bad functional outcome additional sphincteroplasty may be required [grade C].
In conclusion, surgery of perianal abscesses and fistulae show many possible variations. As shown in the literature the surgeonís knowledge about anatomy and function, experience, technical skills and patience of both patient and surgeon is needed to achieve satisfying results [grade B and C].
Colorectal cancer
Incidence
The incidence of colorectal cancer rises with age with a reported incidence of 20 per
There has been a dramatic increase in the population aged over
Screening
Given that 90–95% of colorectal cancers occur sporadically, screening in the older age group (who already have an increased risk of developing colorectal cancer compared to younger individuals) would appear to be of benefit. This is especially true for colorectal cancer where it is known that treat- ment of earlier disease improves prognosis.
Since most colorectal cancers arise within precursor benign polyps there is a long asymptomatic period, of approximately 5 years, prior to a carcinoma developing. This offers the opportunity to detect and treat colorectal cancer at an earlier stage.
Since the symptoms of rectal bleeding and a change in bowel habit are often associated with more advanced disease, earlier detection at the asymptomatic stage becomes of paramount importance if survival is to be improved.
For any form of screening to be effective the disease must be both common and have a well understood natural history. Clearly colorectal cancer meets both these criteria.
This is particularly important in the elderly, where late presentation, often as an emergency, carries a worse prognosis.
The ideal screening investigation, for any disease, should be accurate, acceptable to the patient and inexpensive. If a lesion is detected there needs to be rapid access to confirmatory investigations and definitive management.
Unfortunately all screening investigations that have been assessed to date with regard to colorectal cancer have drawbacks. Faecal occult blood testing has been assessed in five controlled prospective trials, and included patients ranging in age from 45–80, who were asymptomatic. These trials demonstrated earlier detection of disease, compared to the unscreened group, and achieved improvements in mortality of up to 33% in the 0screened population Levin B (1996), Winawer (1995).
Faecal occult blood testing is, however, inaccurate and requires standardization of methodology in order to reproduce these results on a wider scale.
Approximately 50% of colorectal cancers are diagnosable by a
The main drawbacks to flexible sigmoidoscopy are patient compliance, cost and availability of trained practitioners. Maule (1994) demonstrated that nurses trained to do flexible screening sigmoidoscopy are as accurate as gastroenterologists and might help to reduce the problem of cost and availability of practitioners.
Screening with colonoscopy offers the advantage of viewing the entire colon, but has a number of important drawbacks. It requires sedation, there are risks associated with the procedure, it is expensive, is poorly tolerated and would make unacceptable demands upon already stretched facilities. One suggestion is to perform a single screening colonoscopy at age 60, the usefulness of which has not yet been assessed by a randomized study.
Studies in the
Surgical treatment of colorectal cancer
Overall there has only been a marginal improvement in the survival of patients with colorectal cancer in all age groups, related primarily to improvements in postoperative mortality, with the 5 year survival rate remaining approximately 30–40%.
Older patients are more likely to undergo emergency operations which are associated with increased perioperative mortality and reduction in overall survival.
Resection offers the only hope of cure in patients with colorectal cancer and in the majority of those with incurable disease it is the best form of palliation.
Most studies suggest that age alone is not a limiting factor in the surgical management of this disease, rather comorbidity and emergency surgery are confounding factors.
Kingston et al. (1995), in a study of 882 patients, demonstrated similar 5 year survival, morbidity and mortality rates for elderly patients undergoing curative surgery compared to younger age patients. It is the patients fitness rather than age which is the determining factor ie their biological rather than chronological age. Damhuis et al. (1996) in a study of 6457 patients with colorectal cancer demonstrated that even in patients aged over 80, acceptable morbidity and mortality rates could be achieved although resection rates were lower for patients aged over 89. Mulcahy et al. (1994)in a study of 225 patients aged over 70 found that although these patients had a higher rate of emergency presentation compared to a younger age and sex matched group, those patients undergoing curative resection had similar survival rates. Fabre et al. (1993) in a study of 238 patients aged over 75, operated on for colorectal cancer, found that it was the control of postoperative complications related to comorbidity that affected survival rather than the tumor characteristics. Similar results were reported by Arnaud et al. (1991) who demonstrated similar 5 year survival for patients aged above and below 80, if patients dying from non-malignant disease were excluded.
Hessman et al. (1997), in a study of 202 patients aged over 75, reported that the American Society of Anaesthesiologists (ASA) score rather than age alone was a predictor of morbidity and mortality and those patients who underwent curative surgery had favorable 5 year survival rates. Akoh et al. (1994) in a similar study looking at patients aged over 80, again found that it was the ASA class rather than age which predicted morbidity and mortality, with similar 5 year survival rates compared to younger patients, provided they survived the post operative period.
Violi et al. (1998) in a study of 1256 patients operated on for colorectal cancer, divided patients into four age groups; < 60, 60–69, 70–79 and 80+. They found that the age related survival curves for all four groups were similar once age associated causes of death were eliminated. Again the morbidity and mortality rates rose with age as did the number of patients deemed unfit for curative surgery.
Emergency surgery
Overall approximately 20% of patients with colorectal cancer will present as an emergency with an associated poorer prognosis.
This is especially important since the elderly have a higher incidence of emergency presentation compared to younger patients. Anderson et al. (1992), in a study of 645 patients, demonstrated that in those greater than 75 years old, there was a disproportionate incidence of emergency versus elective admissions.
Waldren et al. (1986) in a study of over 1000 patients with colorectal cancer, found that the elderly (n = 522) were more likely to be admitted as an emergency. These elderly emergencies had significantly higher mortality than similar elective patients.
Complications are more often due to comorbid conditions rather than the actual surgery and should be actively identified and treated.
The management of the emergency presentations of right sided tumors is well established with either a right or extended right hemicolectomy remaining the treatment of choice.
The management of acute left sided lesions is more controversial with many units now utilising primary resection and anastamosis with or without a defunctioning stoma as an alternative to a Hartmans procedure.
Although Hartmans procedure is still associated with a relatively low mortality rate of between 2.6 and 9%, staged procedures do have inherent problems, especially for the elderly patient, with multiple hospital admissions and many patients never going onto stomal reversal.
For those that do proceed to reversal of the stoma the morbidity rates range from 5 to 57% and mortality from 0 to 34%.
Primary resection with on table colonic lavage and anastomosis is becoming more common in patients with left sided obstruction with and without perforation. The only contraindications for most groups is gross faecal contamination and septic shock. Age is not a contraindication to this technique and does not appear to be an independent variable with regard to morbidity and mortality.Maddern et al. (1995) reported 40 patients with a mean age of 67 who underwent this technique (32 with covering colostomies) with similar morbidity and mortality rates to groups of similar patients managed with a Hartmans procedure.
Biondo et al. (1997) reported 212 patients with acute left sided pathology of which 63 were treated by on table colonic lavage and primary resection and anastamosis with a clinical leak rate of only 5%.
The Scottia study group (1995) reported the results of a randomized trial comparing colonic lavage followed by segmental resection (n = 44, median age 67) with subtotal colectomy (n = 47, median age 73) and ileocolic anastomosis for malignant left sided colonic lesions. There was no difference in mortality and morbidity between the two groups, with the segmental group reporting better long term ‘bowel’ function.
The importance of a suitably trained surgeon to perform this procedure is stressed in all the above studies if acceptable results are to be achieved.
Adjuvant treatment
Given that up to 35% of patients with colorectal cancer are aged over 65 and at presentation may not be curable by surgery alone, the elderly would appear to be candidates for adjuvant therapy. However with increasing age the dose related toxicity becomes unacceptable to many and renders the treatments suboptimal. Given that adjuvant therapy will only improve survival and quality of life in relatively few patients and is associated with significant complications, it is perceived to be of less use in the elderly.
Newcombe and Carbone (1993) looked at a cohort of women with newly diagnosed breast or colorectal cancer in an attempt to determine whether age affected the type of treatment given. Those aged over 65 were less likely to receive or accept adjuvant therapy and less likely to be referred for a specialist opinion. This is in keeping with similar studies which suggest that the elderly are less likely to receive appropriate tests and adjuvant therapy, regardless of their general health.
Adjuvant therapy in the form of 5 fluorouracil and folinic acid is the most commonly used regimen in colorectal cancer and appears to improve survival especially in Dukes C patients. The question of chemotherapy in the elderly has been assessed in very few trials. Brower et al. (1993) assessed the use of adjuvant 5FU and levamasole in three groups of patients; those aged less than 70, between 70–74 and older than 75. Those patients aged greater than 75 when compared with those aged less than 70 had higher rates of hospitalisation (31 vs. 4%), reduced early dose intensity (0.71 vs. 0.84) and a higher drop out rate (53 vs. 35%).
The use of prophylactic portal vein chemotherapy in patients undergoing resection of primary colorectal cancer without liver metastases appears to improve survival. Given the minimal incidence of complications associated with this technique, which are not related to the patients age, its use maybe more tolerated in the elderly.
Advanced disease
The use of chemotherapy for advanced disease in the elderly is more questionable since the issue of quality of life becomes even more important.
Few studies have addressed this issue. Scheithauer et al. (1993) randomized patients with advanced colorectal cancer to chemotherapy or palliative care only and demonstrated an objective improvement in symptoms in the treatment arm.
In an attempt to improve access to chemotherapy Falcone et al. (1994) assessed the use of oral doxifluridine, a fluoropyridine analogue which becomes converted to 5FU, in a phase II trial involving elderly patients with metastatic colorectal cancer. This study demonstrated improved patient tolerance over systemic 5FU with minimal side effects, producing response rates of up to 14%.
Allen-Mersh et al. (1996) demonstrated an improved quality of life in patients with colorectal liver metastases treated with hepatic arterial chemotherapy, although none of the studies performed to date have focused on the elderly as a separate group.
Liver resection
Approximately 50% of patients undergoing resection of a colorectal cancer will develop liver metastases of which 5–10% will be resectable.
A number of studies have demonstrated improvements in survival in selected groups of patients undergoing liver resection. Such improvements in survival are only achievable if the mortality and morbidity of hepatic resection are kept low and as such should only be performed in specialist centers. Studies have suggested that the elderly tolerate liver resection poorly although more recent studies have demonstrated acceptable morbidity and mortality rates with similar survival to younger patients. These results were obtained by excluding patients with an ASA greater than III, having access to sophisticated intensive care facilities in an experienced tertiary referral center.
Conclusion
The increasing incidence of elderly patients presenting with colorectal cancer has important implications for both health economics and clinical practice. Units dealing with colorectal cancer will need to appreciate the problems associated with this patient population if acceptable morbidity and mortality rates are to be achieved.
Whether or not screening is able to improve disease detection and perhaps influence the natural history remains to be seen and assessed within the context of further randomized control trials.
With the increasing proportion of elderly patients the management of acute left sided colonic lesions will require standardization. Increased use of intraoperative lavage and primary anastomosis may offer an alternative to Hartmans procedure for many elderly patients, who might otherwise be left with a permanent stoma.
Individual patient management should be based on an accurate assessment of the risks versus gains of treatment, with biological rather than chronological age influencing treatment.
Increasing life expectancy coupled with data suggesting similar results to those achieved in younger patients should lead to more flexible treatment protocols for elderly patients with colorectal cancer.
